Shared decision-making with older people on TReatment Escalation planning for Acute deterioration in the emergency Medical Setting - Observed (STREAMS-O): an ethnographic study

Shared decision-making is increasingly expected in healthcare. Treatment escalation planning is a contingency for medical intervention in the event of acute deterioration in hospital. Treatment escalation planning guidelines in the United Kingdom reference shared decision-making but it is not clear to what extent this is feasible. To understand how shared decision-making takes place during conversations about treatment escalation planning between clinicians and patients in the acute medical setting for older patients with mental capacity to participate in decisions about treatment escalation plans. This was a focussed ethnography following a constructivist approach, conducted by a single researcher who is a medical doctor and qualitative researcher with input from a wider research team. Fieldwork took place April-July 2024 in an urban teaching hospital emergency department and acute medical unit. Data was collected as fieldnotes via participant observation, ad-hoc unstructured interviews, documentary analysis and case study analysis. Reflexive thematic analysis was conducted according to Braun and Clarke. There were five themes, which, collectively, illustrated and explained challenges for shared decision-making with older patients in treatment escalation planning in the acute medical setting: ‘A cog in the hospital machine’, ‘One of many good decisions’, ‘A reluctant conversation’, ‘Gatekeeping the decision’, and ‘Unconstructive conversations’. Medical rather than shared decision-making was an inevitability in this context due to a complex set of interlinking factors, whilst patients assumed autonomy over their treatment escalation plan. This study questions the prevailing discourse that shared decision-making is always an optimal and achievable approach. Strategies to enhance shared decision-making in treatment escalation plans might include public education and encouraging clinicians and healthcare organisations to review treatment escalation plan decision-making practice. However, deliberation is required at policy level to determine expectations for different stakeholders’ authority over treatment escalation plans.